Original paper Cite as: Skrzypek E, Mlosek RK: High frequency ultrasound assessment of labial glands High frequency ultrasound assessment of labial glands simulating smallsimulating nodules small or nodulesgranulomas or granulomas after augmentation after lip augmentation. J Ultrason 2020; 20: e261–e267. doi: 10.15557/JoU.2020.0046.

Submitted: High frequency ultrasound assessment of labial glands 27.09.2020 Accepted: simulating small nodules or granulomas after lip 07.10.2020 augmentation Published: 18.12.2020 Ewa Skrzypek1, Robert Krzysztof Mlosek2

1 Department of History of Medicine, Medical University of Warsaw, Poland 2 Ultrasound Diagnostic Department, Faculty of Medical Sciences, Medical University of Warsaw, Warsaw, Poland Correspondence: Ewa Skrzypek, MD, PhD, Department of History of Medicine, ul. Litewska 16, 00-575 Warsaw, Poland; tel. 48 604 075 561, e-mail: [email protected]

DOI: 10.15557/JoU.2020.0046

Keywords Abstract , Aim of the study: The aim of this study is to evaluate the utility of high-frequency ultrasound fillers, in the assessment of the nature and differentiation of lumps occurring in the labial mucosa complications, after lip filling procedures. Material and methods: The study sample included 5 women aged labial glands, from 28 to 43 years (mean age: 37.4 years) who previously underwent a lip augmentation or high-frequency rejuvenation procedure. Photographic documentation was taken and high-frequency ultra- ultrasound sound assessment was performed in all the patients. The presence of deposits, foreign body granulomas, fibrosis and labial glands was mainly investigated taking into account the shape of the abnormalities, their margins, surface area, location and echogenicity. In order to con- firm the diagnosis, histopathological examination was performed. Results: The examinations performed made it possible to differentiate between granulomas and persistent deposit nod- ules and to demonstrate the presence of massive fibrosis and of labial glands pushed out by these abnormalities with the glands presenting as hypoechoic oval areas. Histopathological examination confirmed the morphology of labial glands reported by the patients as uncom- fortable lumps felt from the side of the mucosa, which clinically simulate persistent deposit nodules or granulomas. Conclusions: High-frequency ultrasound is a method that is essential for the correct differentiation between complications of tissue filler procedures. This, in turn, makes it possible to apply the right treatment. In this study, it was demonstrated for the first time that the lumps reported by patients who have had a lip filling procedure may be the result of labial glands being pushed out by deposits, granulomas or massive fibrosis, which are complications of such procedures.

Introduction have a negative effect on the quality and structure of the skin. External factors, including the impact of the envi- Lips are a very important part of facial attractiveness. ronment, exposure to UV radiation or smoking result in a From time immemorial, mainly women have enhanced change of skin integrity. their lips as an indication of youth, beauty and sensual- ity(1,2). Ideal lips are full with well-defined vermilion bor- For this reason, lip augmentation, and thus rejuvena- der. Passage of time and the associated subcutaneous adi- tion using fillers, in recent years mainly those based on pose tissue atrophy, loss of elasticity, effects of gravity and hyaluronic acid (HA), has become a very fashionable and the remodelling of the skeleton and muscles lead to the widely available procedure. When performing this pro- ageing of this area. Beginning in the third decade of life, cedure, one should always take into account the context internal factors such as hormonal and genetic changes of the whole perilabial area set by the base of the nose,

© Polish Ultrasound Society. Published by Medical Communications Sp. z o.o. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial- NoDerivatives License (CC BY-NC-ND). Reproduction is permitted for personal, educational, non-commercial use, provided that the original article is in whole, unmodified, and properly cited. e261 Ewa Skrzypek, Robert Krzysztof Mlosek

the and the chin. From the aesthetic point of view, Material and methods the right proportion between the upper lip and the lower lip is also important, which is 1:1.6 in young Caucasian The study sample included 5 women aged from 28 to 43 women(1,2). years (mean age: 37.4 years) who sought medical help for a complication after a lip filling procedure: they com- There is a rich market of products for reducing any signs plained of small lumps felt from the side of the mucosa of of lip ageing, which include implants, botulinum toxin, both lips, which were sometimes uncomfortable during laser treatments, micropigmentation and fillers, which lip movement. In all the patients, the changes were pre- are the most widely used and most popular solution. viously clinically diagnosed as nodules or granulomas. Fillers play an important role in lip and perilabial area rejuvenation. Photographic documentation were taken and the lip mucosa was palpated. Detailed analysis of the study sample Unfortunately, due to the lack of an ideal filling sub- is presented in Tab. 1. stance, a significant increase in the number of proce- dures and cases when they are performed by unauthor- Subsequently, ultrasound examination was performed ised individuals, there has been a growing number of using the Philips Epiq 5 ultrasound scanner (Philips, complications. Bothel, USA) equipped with an L18-5 broadband linear transducer set to the lowest imaging depth and highest The most common complications of lip filling procedures resolution and the DermaMed high-frequency ultrasound include nodules that are deposits of the filling material and scanner (Dramiński S.A., Olsztyn, Poland) equipped with a foreign body granulomas (FBG). They are very difficult for 48 MHz mechanical sector transducer. clinical differentiation, especially since aesthetic medicine clinics offer a very limited range of tools for diagnosing Next, histopathological examination was performed of complications. small nodules surgically removed from the side of the oral mucosa. The specimens were preserved in 4% buffered for- High frequency ultrasound (HFUS) turns out to be the malin, embedded in paraffin, cut into 4 μm pieces and rou- only effective and non-invasive method for diagnos- tinely stained with haematoxylin and eosin, and additionally ing complications of lip filling procedures. It currently with Alcian Blue pH 2.5 and Periodic Acid-Schiff (P.A.S). makes it possible to differentiate between deposits and granulomas, as well as any other doubtful cases in which diagnosis based on exclusively clinical evidence is simply Results impossible(3). In patients complaining of small lumps felt from the side The aim of this paper is to assess the utility of high-fre- of the mucosa of both lips occurring after lip filling proce- quency ultrasound in the evaluation of clinical diagnosis dures, which were often uncomfortable to them during lip of small nodules or granulomas after lip filling proce- movement, clinical examination involving palpation con- dures. What is particularly important is that histopatho- firmed their presence (Fig. 1). logical studies also confirmed the morphology of these abnormalities observed on ultrasound, similar to an In nearly all cases, ultrasound examination of the lips dem- earlier study on the differentiation between nodules and onstrated filler deposits; in 3 cases, it showed hyaluronic granulomas(3). acid deposits presenting as anechoic focal abnormalities,

Tab. 1. Characteristics of the study sample Time to Ultrasound No. Age at complication Lump site Filler type complication (years Clinical diagnosis diagnosis from procedure) nodules or massive fibrosis, 1. 38 upper lip unknown 12 granulomas labial glands massive fibrosis, nodules or 2. 40 lower lip HA a few times 5 labial glands catching granulomas on the incisors lower lip, nodules or persistent deposits, 3. 28 HA a few times 4 upper lip granulomas labial glands granulomas, upper lip, nodules or 4. 43 PAAG 12 persistent deposits, lower lip granulomas labial glands upper lip, nodules or deposits, granulomas, 5. 38 HA twice 1 lower lip granulomas labial glands HA – hyaluronic acid; PAAG – polyacrylamide hydrogel e262 J Ultrason 2020; 20: e261–e267 High frequency ultrasound assessment of labial glands simulating small nodules or granulomas after lip augmentation

usually oval in shape, with sharp, regular external mar- gins. They were usually accompanied with the indentation of the and minor salivary glands being pushed out, which are seen as hypoechoic, oval, well- defined areas located just below the oral mucosa on exami- nation with the Epiq 5 machine (Fig. 2). In one case, the pushed out glands caught on the teeth, thus being at risk of irritation (Fig. 3).

The use of permanent fillers is usually complicated by granulomas observed on ultrasound as fairly irregu- lar, oval focal abnormalities, sometimes with blurred, uneven external margins. In the present cases, however, the authors observed small labial glands bulging into the oral cavity in the projection of the granulomas mentioned above. Labial glands can also be pushed out by massive fibrosis in the lips observed by the present authors, caused by numerous lip filling procedures, including those using formulations other than the ones based on hyaluronic Fig. 1. Clinical image of a pushed out labial gland presenting as a acid, or by frequent procedures attempting to remove small nodule of the upper lip hyaluronic acid or treat any complications associated with the use of hyaluronidase.

Histopathological examination confirmed that the lumps reported by the patients, which were clinically diagnosed as nodules or granulomas, were in fact normal seromucous minor labial glands (Fig. 4).

Discussion

Lips are skin and muscle folds built of 3 parts: skin, mucosa and the middle part in between (Fig. 5). The labial glands, which are the focus of the present study, were located mainly in the submucosa of the internal part, even though they are usually distributed in the space between the Fig. 2. Ultrasound image (Philips Epiq 5) of a hyaluronic acid deposit mucosa and the orbicularis oris, and some of them are also (arrow head) indenting the orbicularis oris (bold arrow) and la- found in the muscle layer(4). bial glands (thin arrows) The oral cavity and the oropharynx are lined with approx. 600–1000 minor salivary glands of 1–5 mm. The larg- est number of these glands are found in the lips, buccal mucosa, the and , but they are also found in the tonsils, epiglottis and paranasal sinuses(5). The names of the glands are associated with their location: e.g. labial, buccal, lingual. They resemble major salivary glands in his- tological terms; however, they are much smaller and less branched than their major counterparts. Every minor sali- vary gland is composed of multiple secretory units and has a short single duct transporting a primarily mucous secre- tion, but also serous and mixed secretion, directly into the oral cavity. This secretion is necessary for keeping the oral mucosa moisturised and protect it and the teeth against pathogens. Approximately 6–10% of the total saliva volume comes from these minor glands(4–7).

The lower lip has a higher density, secretion volume and number of active units of minor glands than the upper lip(8). Fig. 3. Ultrasound image (Philips Epiq 5) of a hyaluronic acid de- posit (arrow head) in the lower lip pushing out a labial gland (thin arrow) catching on the upper incisor (bold arrow); ma- The success of a lip augmentation procedure depends xillary mucosa (asterisk) on good understanding of , on the technique

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for an ideal filler, i.e. a material that primarily achieves the best, long-term effects, causes the lowest number of complications and generates low costs. The main char- acteristics of an ideal filler should also include non- toxicity, non-carcinogenicity, non-immunogenicity, bio- compatibility, plasticity, physical stability and clinical manageability(10). It seems particularly difficult to find A B such a material for lip augmentation. The use of liquid silicone, which became very popular in the 20th cen- tury, is currently forbidden in many parts of the world, such as, for example, in the United States of America or the European Union. Nevertheless, in certain coun- tries of Southern Africa or the Far East, this filler is still popular and accepted(11). However, many individuals are still suffering from late side effects of procedures performed some years ago. The latest guidelines recom- C D mend that the use of permanent fillers mentioned above Fig. 4. Labial glands removed as a whole, clinically diagnosed as no- and semi-permanent fillers such as calcium hydrox- dules or granulomas after a filling procedure. A. and B. Ha- ylapatite (CaHA) and poly-L-lactic acid (PLLA) for lip ematoxylin and eosin (HE). C. Periodic Acid-Schiff (P.A.S.), augmentation be avoided(12). In 2006, the U.S. Food and mucus-secreting areas (arrows), serous areas (arrow heads). Drug Administration approved a formulation based on D. Alcian blue, serous cells (S), mucous cells (M) PMMA microspheres suspended in a 3.5% atelocollagen solution, which is designed for lip procedures, among used, the appropriate selection of filler substance and others(13). a sense of aesthetics that allows one to create a natu- ral appearance in the patient(9). This can be achieved by There are also cases of lip augmentation using prohib- using temporary/degradable/resorbable substances such ited substances such as, for example, vitamin A, E and D as collagen or hyaluronic acid or permanent materials. extracted from gel capsules(14,15). Permanent/non-resorbable fillers include polymethyl methacrylate (PMMA) with or without collagen as a Hyaluronic acid (HA) is currently the leading filling vector, polyacrylamide hydrogel (PAAG), hydroxyeth- material used for lip filling and reduction of wrinkles ylmethacrylate/ethylmethacrylate (HEMA/EMA) with in the area, chiefly due to its temporary nature, degrad- hyaluronic acid and liquid silicone (polydimethylsilox- ability, effectiveness, versatility, diversity with over 200 ane, PDMS)(8). However, none of them meets the criteria different HA-based formulations present on the market

HAIR FOLLICLES SEBACEOUS GLANDS TRANSITION ZONE EPIDERMIS

DERMIS

ARRECTOR PILI MUSCLE BLOOD VESSELS:

ARTERY VEIN ORBICULARIS ORIS MUSCLE

ADIPOSE CELLS

ORAL EPITHELIUM LABIAL GLANDS

Fig. 5. Lip structure. Drawing by Ewa Skrzypek e264 J Ultrason 2020; 20: e261–e267 High frequency ultrasound assessment of labial glands simulating small nodules or granulomas after lip augmentation

Tab. 2. Hyaluronic acid-based fillers for lip augmentation in adults and lip wrinkle reduction approved by the U.S. Food and Drug Admi- nistration Date of approval Product/manufacturer Material Indications 2020 Restylane Kysse / Galderma Laboratories, LP 20 mg/ml; HA, 0.3% lidocaine lip augmentation, lip wrinkles 2016 Juvéderm Volbella XC / Allergan, Inc 15 mg/ml; HA, 0.3% lidocaine lip augmentation, lip wrinkles 2015 Juvéderm Ultra XC / Allergan, Inc 24 mg/ml; HA, 0.3% lidocaine lip augmentation, lip wrinkles 2014 Restylane Silk / Galderma Laboratories, LP 20 mg/ml; HA, 0.3% lidocaine lip augmentation, lip wrinkles 2012 Restylane-L / Galderma Laboratories, LP 20 mg/ml; HA, 0.3% lidocaine lip augmentation, lip wrinkles 2011 Belotero Balance / Merz Aesthetics 22.5 mg/ml; HA lip wrinkles 2011 Restylane / Galderma Laboratories, LP 20 mg/ml; HA lip augmentation, lip wrinkles HA – hyaluronic acid

and a favourable safety profile (Tab. 2). Various proce- characteristically thin mucosa(21). This contributes to the dures are used, from the ones which increase general new complication observed by the present authors, which lip volume, define the and eliminate is very significant in diagnostic terms, but has not been asymmetry to the ones which enhance and highlight the reported in the literature to date: small salivary glands lips and reduce the depth of lines and wrinkles around within the labial mucosa being pushed out by the filling the lips. material.

Even though such procedures are among the most popu- For this reason, it is not surprising that high frequency lar ones, unfortunately, they are constantly associated ultrasound scanning and histopathological examination with a large number of possible complications. The play a huge role in the diagnosis of complications after soft number of such complications has been constantly ris- tissue filling procedures, particularly suspected abscess, ing because of the mere increase in the number of proce- overcorrection, incorrect administration of the filling mate- dures and cases when unauthorised individuals perform rial, migration, fibrosis, foreign body granulomas, persis- them. Depending on the time of occurrence, complica- tent deposit nodules and compression or embolisation of tions can be divided into early and delayed although the a vessel(22). latest reports classify them as immediate onset: up to 24 hours after the procedure; early onset: from 24 hours High frequency ultrasound makes it possible to precisely to 4 weeks, and delayed onset: more than 4 weeks fol- identify all lip structures, including small labial glands lowing the procedure(16,17). Immediate- and early-onset observed as hypoechoic oval areas located just below complications typically occur within hours or days the oral mucosa (Fig. 6 and Fig. 7). However, it needs after the procedure, while delayed complications usu- to be emphasised that ultrasound scanning using devices ally develop within weeks or even years after the injec- equipped with mechanical, single-element transducers tion(18). Early-onset complications are well-known and do has a high diagnostic value since they allow one to obtain not differ depending on the filler used. Such complica- images with higher resolution, resulting in a higher level tions are usually associated with errors in the injection of detail (Fig. 6) compared to images generated by clas- technique or infections and manifest themselves with sic machines (Fig. 7). With such equipment it is easier to prolonged oedema, redness, petechiae, pruritus or pain. differentiate between labial glands and filler deposits or The lip area is also susceptible to herpes virus reacti- granulomas. In ultrasound images obtained using a 48 vation. Tissue necrosis is a rare but significant early- MHz transducer, labial glands are seen as hyperechoic onset complication, which is caused by compression, or, areas with irregular margins and linear hyperechoic more commonly, embolisation of a vessel by the material reflections correlating with histopathological presen- administered(19). Theoretically, based on research, vision tation. The above is also true for the morphology and loss is a potential complication of filler injection in this function of different parts of the orbicularis oris muscle. area(20). Delayed-onset complications, on the other hand, Ultrasound has been increasingly commonly used in the caused by product migration, acute or recurrent tissue diagnosis of complications after lip filling procedures oedema, infection, and the formation of nodules, granu- since it is non-invasive, safe for the patient, relatively lomas, fistulas and fibrosis can be filler-specific(11). cheap and easily available(3,23).

The most commonly observed side effect in the lip area after filler injection are nodules or granulomas of various Conclusions sizes. The lips, like the eyelids, have a thin tissue cover; therefore, for instance, the administration of an exces- The lips are one of the most important parts of facial sive amount of filler results in lumping or dislocation of attractiveness; therefore, reducing the effects of ageing of the material caused by the movement of active muscles in this particular area and increasing its attractiveness has the area. Apart from that, lips have a high mobility and a a prominent place among aesthetic medicine procedures.

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Fig. 6. Ultrasound (DermaMed with 48 MHz transducer) transverse Fig. 7. Ultrasound (Philips Epiq 5) longitudinal plane of normal labial plane of normal labial glands (thin arrows); orbicularis oris glands (thin arrows); orbicularis oris (bold arrows); lip mucosa (bold arrows); lip mucosa (arrow head) (arrow head); teeth (asterisk)

Despite the fact that primarily hyaluronic acid-based for- For instance, this excludes the use of hyaluronidase in such mulations have been used for these procedures in recent cases, which is currently an established part of the algo- times, they are still associated with the risk of numerous rithm for the treatment of nodules after hyaluronic acid complications with uncertain diagnosis. It needs to be injections. The importance of ultrasound and histopatho- emphasised that accurate diagnosis of complications trans- logical examination is also supported for complications lates into adequate treatment. after tissue-filling procedures as the only methods that allow one to make the correct diagnosis, and, consequently, An increasing number of women have been seeking apply proper treatment. medical help having undergone lip filling procedures. They report a complication involving small nodules/ As mentioned previously, the above determination of the lumps felt from the side of the labial mucosa, which are exact nature of the small lumps in both lips that were sometimes uncomfortable during the everyday activity reported as a complication and erroneously interpreted of this area. Sometimes the patients experience a sense clinically as nodules or granulomas is the first such report of irritation, mild pain or a feeling of piercing and/or in the literature, with a huge diagnostic and therapeutic burning. value. This is because a consistent list of complications after tissue filling procedures remains to be developed, Earlier reports regarding ultrasound differentiation with the associated specific diagnostic and therapeutic between nodules and granulomas which included his- algorithms. topathological examination made it possible to develop an algorithm for their differentiation using non-invasive ultrasound imaging, since clinical differentiation is rarely Conflict of interest possible(3). The authors do not report any financial or personal affiliations to The discovery of the actual nature of the small abnormali- persons or organisations that could adversely affect the content of or ties described above occurring after lip filling procedures claim to have rights to this publication. using hyaluronic acid-based formulations, which were previously considered to be only nodules or granulomas, makes the correct diagnosis and treatment possible.

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